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Back Pain: When Surgery is Appropriate

Online Health Chat with Dr. Russell DeMicco

February 17, 2012

Introduction

Cleveland_Clinic_Host: Trauma, aging, improper body mechanics, and normal wear and tear can all injure your spine. Damage to any part of your back or pressure on the nerves in your spine can cause back pain and other symptoms. If you have ongoing back pain, maybe you have wondered — “could back surgery help?”

 

Most back problems can be taken care of with nonsurgical treatments, such as anti-inflammatory medication, ice, heat, osteopathic manipulation, spinal injections, and physical therapy. When conservative treatment options do not provide relief, back surgery may be an option. However, it does not help every type of back pain. Back surgery is typically only needed in a small percentage of cases.

Here are some common reasons as to when back surgery might be needed: vertebral fractures or conditions related to osteoporosis, fractured vertebrae, some instances of bulging or herniated discs, or compression of the spinal nerves.

When should you see a back pain specialist? When back pain is severe or persistent, evaluation by a medical spine specialist is recommended. Warning signs that should prompt urgent medical evaluation include the presence of fever, worsening pain, progressive movement of the pain from the back into the leg, numbness in the area of the injury or down the leg, presence of a lump or area with an unusual shape, and pain that is unrelieved at rest or disturbs sleep.

Russell DeMicco, DO, is a medical spine specialist with the Center for Spine Health and sees patients at Twinsburg Family Health & Surgery Center and Cleveland Clinic main campus. His specialty interests include the evaluation and management of back pain in adults and adolescents, non-operative spine care and musculoskeletal medicine, and interventional spine procedures. He has been on staff at Cleveland Clinic since 2003 and is also certified in Physical Medicine & Rehabilitation.

To make an appointment with Russell DeMicco, DO, or any of the specialists in the Center for Spine Health at Cleveland Clinic, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at clevelandclinic.org/spine

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Russell DeMicco. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Stenosis

strom: Is there any way to prevent spinal stenosis as you age?

Dr__DeMicco: No. Stenosis will develop in people who live long enough to acquire enough degenerative changes. Exercising, maintaining good diet and appropriate weight, as well as avoiding tobacco may help retard the degenerative changes compared to smokers who do not exercise and are overweight.

nancyhanks: If spinal stenosis is left untreated, will it damages nerves in your bladder/bowel? What are the symptoms of this damage and can it be treated if you are unable to tolerate surgery?

Dr__DeMicco: Everyone who lives long enough will develop spinal stenosis from an accumulation of degenerative changes through wear and tear of the spine. Not everyone with stenosis is symptomatic. Pain that is worse with standing and walking and is reduced with sitting sounds like stenosis. Most people will not develop weakness or changes to bowel or bladder. If you do develop these, it may be a sign of cauda equina syndrome (a rare but surgical emergency).


Spondylolisthesis

mschnip: I have a 12 mm L5-S1 spondylolisthesis with moderate to severe encroachment. I have a minimal loss of sensation in my left foot and calf, without pain. Can this condition be controlled, or reversed, without surgery? If so, what are your suggestions?

Dr__DeMicco: Sensory symptoms may be treated with directed exercises developed between you and a physical therapist and potentially with medications (developed for seizures but used for numbness and tingling), if bothersome. Surgery is typically done if the spine is unstable or for recalcitrant pain. It may also be done to halt progression of weakness. However, surgery is not done to make you stronger. PT and exercises are done for that.

JJ1234: L5-S1 grade 2 spondylolisthesis. What if the vertebra slips to grade 3 or higher? Surgery then?

Dr__DeMicco: Maybe. Surgery is typically done based on symptoms, response to treatment, and discussion between surgeon/patient.


Specialists

myadvocate: How does a patient sort out care for what may be a back problem between a neurologist, a spine surgeon, a PMR specialist, a pain management specialist, and perhaps others when trying to find out what is wrong. I have pain that goes from my ribs down to my feet with varying intensity in different places. Classic medical problems like diabetes have been ruled out.

Dr__DeMicco: Certain specialists may help to diagnose problems. There is overlap between specialists. I would typically stick with someone you trust that has a good understanding of the questions you are looking to answer and the work-up that has been done. Two main questions are usually: What is the diagnosis? What can be done for the diagnosis?

nothing_compares: How do you know when to use an ortho or a neurosurgeon for my back surgery?

Dr__DeMicco: We have spine surgeons here (both neuro and ortho) who are used the same. They are all well-trained and specialize in only the spine.

I would usually check that they are board certified and/or fellowship trained. Some surgeons further specialize to just certain types of problems (only back or only neck). Some prefer minimal access or minimally invasive approaches while others do it all.


Options

JRofOC: When pain management doesn't help, what are other alternatives for back pain due to bulged discs and arthritis?

Dr__DeMicco: I usually advise people that options are nothing (leave it alone), exercise, medications, injections, surgery, or other (non-traditional like acupuncture, tai chi, or even cognitive behavioral therapy). Most people will do well with exercises and medication if needed. Surgery is usually done for so-called radicular or sciatic pains that don't get better with exercises, medications, or time. Injections may be considered for pain not relieved with time, exercise, or medication.

DASHOIH: I have been experiencing shooting pains in my legs along with some numbness. This has been going on since the end of last October. I have gone through four weeks of physical therapy and have subsequently received an MRI. The PT has helped relieve stiffness but not pain. The MRI shows stenosis at L3-L4 (significant) and L4-L5, as well as a herniated disc at L5-S1. Surgery has been recommended. Is there anything else I can do to do to relieve symptoms and avoid surgery?

Dr__DeMicco: Aside from PT and home exercises, patients may try medications and even injections for relief of pain. Medications vary from NSAIDs (Advil®, Aleve®, or others by prescription) to analgesics (pain pills) to membrane stabilizers (drugs developed for seizures or depression that may help pain). Injections can be epidural steroid injections.

enortep163: I am a 59-year-old male, disability retired due to heart disease and degenerative disc disease. I have multiple disc herniations, spinal stenosis, curvature of the spine, etc. My question is that my cardiologist and the opinion of Cleveland Clinic pain management in Weston that to do facet injections I would have to stop aspirin, Plavix® (clopidogrel), and fish oil, which the cardiologist does not want me to stop, so what do I do now? I’ve tried all conservative treatments except acupuncture. Had two surgical consultations, and all the surgeon wants to do is cut me, screw nuts and bolts and fusion, with no guarantee of no more back pain. I've been on narcotic pain management for 7+ years now, recently stopped 3 months now, 30mg Roxycodone 4 x per day and escalating---now take Ultram® (tramadol) 400mg per day and Lyrica® (pregabalin). I can’t get the shots, I don’t want surgery. I'm thinking of going back on narcotics --- caught in "Catch 22." West Palm Beach.

Dr__DeMicco: This is tough. The injections are elective and may not be worth the risk of stopping heart medications and such. Medications aside from opioid or narcotic analgesics may be considered. Cognitive and behavioral therapies have been shown to be helpful for people with degenerative disc disease when compared to fusion.

Linda_Kelly: Female, age 61, diabetes, RA, back issues L3/4, L4/5. Have had 15 sessions of PT and have been working out at local gym, concentrating on strengthening core and upper back. When I return to my neurologist next week, what questions should I pose to help him determine the next course of treatment, be that surgery or other treatment?

Dr__DeMicco: The diabetes and RA put you at greater risk for complications with surgery. The question would be: is it pain in the back or legs that bothers you?

The PT move to an independent program sounds right. Medications or injections are the options between exercises and surgery.

Make sure your neurologic exam has not changed and there is nothing that the doctor is noticing that you maybe have not noticed yourself.


Medications

william1234: Male age 78, health excellent, golf, tennis, bike, weight train daily. Decompressive lumbar laminectomy w/ fusion four years ago--pain never totally relieved and getting progressively worse, cannot stand upright and still more than few seconds--no pain with above activities. Medication that provides most relief is dexamethasone 1 mg--take 440 mg of naproxen daily, wear brace daily, have had 24 sessions of deep heat massage by physical therapist, relief is brief. Surgery left L4/L5 overhang of 1 cm--was three prior surg. Surgery option is last resort. Can you suggest therapies or medications that have potential for relief?

Dr__DeMicco: Steroids are limited in long-term use because of potential negative factors (diabetes, weight gain, etc.). Are you concerned about hunching over or pain?

Most doctors would limit uses of naproxen and NSAIDs for pain after age 65. Other medications and directed exercises are recommended. Massage and modalities-based treatment such as heat, ice, and electrical stimulation may provide only temporary relief.

Harry46041: Curious, why after age 65 on limiting NSAIDS?

Dr__DeMicco: Increased risk for complications (ulcers, kidney problems, heart issues).

Usually start with acetaminophen as first-line analgesic and look at other options beyond if that does not help.

ccchats2172012: I am the 78-year-old male you replied to earlier. Which medications do you suggest other than the dexamethasone 1gm as prescribed plus the 220 mg naproxen x 2 daily?

Dr__DeMicco: Without examining you or looking at your scans, I would defer to your regular physician with regard to which medications to try and may work best for you.


Surgery

abuelatuck: What are the risks of having an endoscopic procedure (entering through the natural opening in the sacrum area) to shrink a herniated lumbar disc and correcting lumbar spinal stenosis with laser? Are there a number of back surgeons who do this procedure?

Dr__DeMicco: Risks from endoscopic (aka minimal access or minimally invasive) surgery are generally the same as other surgeries -- infection, bleeding, injury to nerve and such. Laser procedures are done across the country but by limited providers.

JJ1234: When all other options for pain relief have been tried and failed, and surgery must be considered, is a person with grade 2 spondylolisthesis a candidate for MINIMALLY INVASIVE spinal fusion surgery? I saw this type of surgery on the CCF spine website. Thank you.

Dr__DeMicco: Just because everything has not worked does not mean that surgery will. Fusion surgery can be done for spondylolisthesis through a minimal access approach. This is typically the same procedure done as an open procedure, just through a smaller window or opening. Most successful surgery is done to relieve pain shooting into the lower limbs more than it is to relieve low back pain.

JJ1234: Would spinal fusion surgery for spondylolisthesis alleviate any of the symptoms of the condition such as low back pain and tight hamstrings?

Dr__DeMicco: Spine surgery is great for relieving pain shooting into the lower limbs from spinal stenosis or pinched nerves. Unfortunately, the results of surgery for back pain are mixed. It may be 50/50. In the 50 percent that may not get better, there may be a 10 percent to 20 percent group who feel worse. If the lower limb symptoms are debilitating and you can tolerate the low back pain, surgery may be worth discussion if all else (medications, exercises, injection) has not provided the relief sought. Stretching is usually the way to go for tight hamstrings.

mko098: Is it common to experience lower back pain after spinal fusion and removal of all hardware? I had the surgery about a year ago.

Dr__DeMicco: Low back pain is a very common problem in people with or without a history of surgery. Having hardware removed may or may not help. I would typically go about treating the low back pain conservatively and progress from there.

The trick is that there are many causes for back pain (discs, nerves, ligaments, tendons, muscles, and joints). The pain may also be from other organs.

jomickler: I was recently diagnosed with a totally disintegrated disc between L3-L4. I was told if I can live with the pain, fine. If not, then they will need to fuse L3-L4. So far, I am living with the pain. What kind of damage am I doing to the adjacent vertebrae if I put off surgery? Likewise with the surgery, how will the fused L3-L4 affect the adjoining vertebrae? Pain in my back has been a constant companion. I fractured L1 at an early age, now have arthritis in that area, a number of crushed or bulging disc from a bicycling accident. Thanks, John Mickler.

Dr__DeMicco: I usually advise patients of the difference between hurt and harm. You are not likely doing any additional damage by continuing with activities as tolerated. Strengthening the muscles that support the area and aerobic conditioning are recommended for back pain. The spine shows wear and tear as we age. Having a fusion surgery may or may not help pain and will lead to accelerated wear and tear at other levels.


Post-Op

mschnip: Is it true that after a lumbar fusion that the patient is limited to lifting only about 25#?

Dr__DeMicco: Depends. Restrictions are usually surgeon or hospital dependent or unique to patient and case.

mschnip: Are those restrictions common? I am a self-employed HVAC tech and inability to lift 80 to 100# would put me out of work.

Dr__DeMicco: Restrictions may be in place for a limited time. Others may leave lifting restrictions in place forever. Make sure with surgeon before you decide.


Injections

nance: Spondylolisthesis with degenerated disks, herniated probably, with sciatica. Do you recommend epidural injections?

Dr__DeMicco: I advise most people that time and exercise go a long way. I would look at injections to relieve pain not relieved with medications or exercises. Otherwise, injections may be done to help surgeons define a specific level for which they would want to operate. (Injections can give a preview of pain relief anticipated from surgery.)

Symplyme_2: Is there a maximum number of epidural injections that should be administered? Dr__DeMicco: We typically do not look at injections to be done in a series of three. I would do one and see how you do. If not better, would try another approach or different level. If the patient got great relief, you would ride it out and see how long it lasts. If you get partial relief, we may consider a repeat.

Try to do the least amount needed. Some people would require more than one. Limitation (some say no more than four to six per year) is usually based on not wanting negative effects (weight gain, osteoporosis, elevated blood sugar, and cataracts, among other things) that are usually associated with long-term use.

nance: How do you feel about transforaminal epidural nerve block injections for ongoing low back pain with sciatica? I am 80 years old.

Dr__DeMicco: If you get enough or long-lasting relief with the procedure, there is likely not a reason not to get injection again should pain recur or return to > 50 percent of pre-procedure level.


General Questions

ziporah: What can be done for severe curvature of the spine on an 80 year old?

Dr__DeMicco: Risks for surgery are likely high. However, evaluation and opinion from a surgeon who does deformity correction may be worthwhile. Otherwise, you may look at treating any pain with PT/exercises, medications, or even bracing in some cases.

Harry46041: Do you have an opinion on chiropractic manipulations for a patient with DISH syndrome and spondylitis I also have stenosis in both cervical and lumbar spine areas. Thanks.

Dr__DeMicco: Manipulation (osteopathic or chiropractic) may be useful for acute episodes of axial low back or neck pain (that does not shoot into the upper or lower limbs). DISH [diffuse idiopathic skeletal hyperostosis] is a difficult problem. Rack ‘em and crack ‘em (high velocity and low amplitude) manipulation is not likely recommended. Myofascial techniques may be tried.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Russell DeMicco is now over. Thank you again, Dr. DeMicco, for taking the time to answer questions about 'Back Pain: When Surgery is Appropriate.'

Dr__DeMicco: Thanks for all the great questions. There is a wealth of information from the Internet and physicians available. Keep it simple -- look at answering the two main questions (what is the problem and what can be done for the problem). Work with someone you trust.


More Information

To make an appointment with Russell DeMicco, DO, or any of the specialists in the Center for Spine Health at Cleveland Clinic, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at clevelandclinic.org/spine

You may request a remote second opinion from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult.

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